In this era of health care reform, there is greater scrutiny than ever before of health care–related costs and appropriateness of testing services. There has been a noticeable shift from a practice of broad diagnostic screening to a more targeted testing approach. This new best practice is expected to significantly alter the way that health care is delivered throughout the United States. Over the last decade, all modalities of echocardiography have rapidly expanded in utility and availability. Transthoracic echocardiography (TTE), in particular, is now routinely available in almost all acute inpatient facilities, outpatient centers, and many emergency rooms. Miniaturization of technology has allowed smaller and less expensive platforms to be developed, thereby enabling greater access to and more portability of this technology. The relatively low cost, absence of radiation, and ability to perform studies at the bedside has placed echocardiography at a significant advantage over other techniques including cardiac computer tomography, magnetic resonance imaging, and nuclear medicine.

Given this rapidly expanding utility of echocardiography, there has been a perception that it is overused and potentially employed inappropriately in many instances. Although these claims have never been substantiated, they have gathered traction amongst the medical community and resulted in documented appropriate use criteria (1). Hence, the paper by Papolos et al. (2), in this issue of the Journal, is a timely analysis of echocardiography utility within the U.S. hospital system. With the assistance of the Nationwide Inpatient Sample (NIS), they were able to examine trends in use of echocardiography over a 10-year period from 2001 to 2011. This sample encompassed data on approximately 8 million annual hospitalizations from approximately 20% of community hospitals in the United States. They then used the data from 2010 to correlate all cause in-hospital mortality with echocardiography utilization.

Papolos et al. (2) began by identifying the most commonly associated conditions for which echocardiography is deemed appropriate according to current best clinical practice. These included acute myocardial infarction (AMI), cardiac dysrhythmias, acute cerebrovascular disease, congestive heart failure, sepsis, coronary artery disease, valvular disease, and nonspecific chest pain. Statistical modeling was then employed to determine the relationship between diagnostic testing and all-cause inpatient mortality. Given the inherent limitations associated with a database of this nature, the authors subsequently replicated and validated their findings within their own institution.

As expected, they found that the use of inpatient echocardiography has been steadily increasing at an average rate of approximately 3% per annum over the last decade. More importantly and perhaps surprisingly, performance of echocardiography was also associated with reduced inpatient mortality in the first 5 of the clinical categories listed previously. Somewhat unexpectedly, echocardiography was actually only performed in 8% of the eligible 3.7 million hospitalizations for these pre-specified indications. Papolos et al. (2) confirmed that echocardiography was underutilized for these same conditions within their own hospital cohort, though to a lesser degree than for the study population as a whole.

The counterintuitive findings from Papolos et al. (2) are particularly interesting, as they debunk the widespread perception of echocardiography overuse. Additionally, more importantly, they highlight the low utilization of echocardiography in currently recommended indications such as AMI, heart failure and cerebrovascular disease, even though echocardiography use was actually associated with reduced hospital mortality. These findings may reflect in part the limited availability of echocardiography in some regional centers or suboptimal “out-of-hours” coverage, but it seems hard to believe that accessibility is truly an issue in 92% of admissions for these conditions. Some subjects may have had a recent outpatient echocardiogram and thus inpatient testing was thought to be unnecessary. However, if the patient was symptomatic enough to require an acute cardiac admission, surely the change in clinical status should warrant a repeat echocardiogram as is specified in the echocardiography appropriateness guidelines (1)? In this scenario, the costs associated with diagnostic imaging would be arguably offset by more accurate diagnosis and subsequent ability to optimize treatment in a more timely fashion. In fact, the increased mortality rates associated with the failure to utilize echocardiography suggest that any additional costs may be justified by superior clinical outcomes.

In many ways, the documented annual increase in echocardiography volume appears relatively modest, but in keeping with previous findings (3). Another surprising finding emanating from this analysis is the paucity of echocardiography use with AMI and coronary artery disease, despite strong guideline recommendations (4,5). Although approximately two-thirds of subjects underwent diagnostic coronary catheterization with presumed ventriculography, there still remained approximately 30% of subjects with both of these conditions who had no inpatient assessment of ventricular systolic function. For those fortunate few who did have echocardiography, there was a clear reduction in all cause hospital mortality in the setting of AMI. These findings were corroborated in the authors’ home institution.

As with most studies, there are some inherent limitations of this manuscript, which limit its generalizability. Incorrect coding for performance of echocardiography may have led to an underestimation of echocardiographic utilization. The inability to clearly differentiate between TTE and transesophageal echocardiography from the codes utilized within the NIS database also needs to be acknowledged. However, this implies that TTE numbers were even lower than described and reinforces the message of potential underutilization. The apparent protective effect of echocardiography may be possibly explained by the fact that those subjects who received echocardiography also experienced a higher standard of care overall, perhaps facilitated in centers with more subspecialty availability. The authors partially refute this by showing that there was no difference in distribution of echocardiography utilization according to medical center size, but clarity regarding other variables is beyond the scope of the NIS database. Highest rates of echocardiography use were noted throughout the east coast, arguably substantiating that greater availability of subspecialty involvement was an influencing factor in utilization.

While advocating for increased utilization of echocardiography seems justified based on the findings of this paper, maintenance of quality standards according to approved recommendations remains paramount and is strongly advocated (6). Performance of echocardiography by inexperienced or unqualified providers could have detrimental effects and result in incorrect or missed diagnoses and inappropriate management. Handheld devices are becoming more popular, particularly in the intensive care and emergency room settings, but remain limited in diagnostic capability. These platforms also have minimal ability to record images, thereby limiting the ability to corroborate findings or compare for interval change. This is particularly concerning as often the patients being examined with these devices at the bedside are the sickest, have the most technically challenging acoustic windows and have the most complicated pathology. Increasingly, too, these tools are being used by physicians other than cardiologists who have limited training at best in their use. At this time, therefore, the use of such alternative diagnostic tools cannot replace the comprehensive evaluation provided by a complete TTE including 2D imaging, comprehensive Doppler interrogation and volumetric analysis. In many of these challenging cases, the further use of echo contrast, 3D imaging and even transesophageal echocardiography by experienced operators can have a significant impact on diagnosis and management (7–9).

We live in an era of cost repositioning and evolving health care policy. Although the charges associated with echocardiography must always be considered, this should not be at the detriment of patient care and outcomes. In comparison with other advanced cardiac testing such as cardiac computer tomography and magnetic resonance imaging, echocardiography often provides better value and is eminently more practical for sicker patients. The increasing practice of “cost bundling,” whereby a fixed fee is paid for the entire hospital admission, may be a disincentive for repeat diagnostic testing, even if there is a change in clinical status and this may be at a potential cost to the clinical outcome as suggested by this paper. To further reduce inpatient testing and enable billing outside of bundling agreements, scheduling of repeat echocardiography after discharge is becoming more commonplace. In part, these practices may have already influenced some of the data presented within the manuscript as the authors acknowledge.

Papolos et al. (2) present a thought provoking insight into the current reality of echocardiography utilization in the United States. Their findings strongly suggest an actual underuse of this technology in conditions where it has most proven value. The illustrated relationship between the use of echocardiography and better clinical outcomes does not necessarily imply causality. Prospective studies are required to determine if these findings can be replicated more broadly and if outcomes can be directly influenced by consistently adhering to appropriateness criteria and guideline recommendations for performance of echocardiography. In the meantime, this paper reminds us that underutilization of safe, effective technologies such as echocardiography may also have a broad economic impact and that health care strategies that may limit their utilization should be subjected to clinical trials and the cleansing light of actual data.

Footnotes

↵∗ Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology.

Both authors have reported that they have no relationships relevant to the contents of this paper to disclose.

(2014) 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol64:e139–e228.

(2004) ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of patients with acute myocardial infarction). J Am Coll Cardiol44:671–719.

(2014) Association of outcome with left ventricular parameters measured by two-dimensional and three-dimensional echocardiography in patients at high cardiovascular risk. J Am Soc Echocardiogr27:65–73.

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